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SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> �'OF. O1 DICE USE1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> Id <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74L � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2�- <br /> (Complete In Triplicate) J,,1: 00'7- RO-Z3 <br /> Application is hereby made to the San Joaquin Local:Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Coun-yt -Ordinance..No._ 1862 and the Rules and Regulati n of th San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION + 17.4 CENSUS TRACT ' <br /> Owner's Nam Phone <br /> AddressCY <br /> City <br /> Contractor's Name r - 'cense # hone <br /> - �- Y <br /> TYPE OF WORK (check) : NEW WELL DEEPEN/ / RECONDITION/ / DESTRUCTION /? <br /> PUMP TNST LATION I I PUMP REPAIR / / PUMP REPLACEMENT I-T <br /> Other •/ <br /> DISTANCE TO NEAREST: SEPTIC TAi4K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE-OF-WELL CONSTRUCTION SPECIFIC IONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 72, <br /> Irrigation P Gravel Pack Depth of Grout Seal ..._ <br /> Other Rotary Type of Grout i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:_ / / State Work Done <br /> PUMP 'tEPAIR: / / State. Worn Done <br /> I� Approximate Depth <br /> ,DFfiTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a . <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> t information true to the t of my knowledge and belief. <br /> f ► . <br /> t SIGNED 7 TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I D DATE <br /> `h APPLICATION ACCEPTED BY <br /> ADDITIONAL CQMN,ENTS: PHASE II /FINAL INSPECTIO <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / 11 <br /> CALL FOR. A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br /> - - , ,.,� <br />